The Noonday Demon (35 page)

For other children, though recovery seems impossible, accommodation is not. Christie describes treating a girl with horrible chronic headaches, “like banging hammers in my head,” who had given up everything in her life because of the headaches. She couldn’t go to school. She couldn’t play. She couldn’t interact with other people. When she met Christie for the first time, she announced, “You can’t make my headache go away.” Christie said, “No, you’re right. I can’t. But let’s
think about ways to keep that headache all in one piece of your head and see if you can’t use another piece of your head even while the hammers are hammering in there.” Christie notes, “The first step is to believe what the child says even if it’s apparently untrue or implausible, to believe that even if the child is using metaphoric language that doesn’t make sense, it must make sense to them.” After extensive treatment, the girl in question said she could go to school despite her headaches, and then she began to have friends despite her headaches, and within another year, the headaches themselves were gone.

The elderly depressed are chronically undertreated, in large part because we as a society see old age as depressing. The assumption that it is logical for old people to be miserable prevents us from ministering to that misery, leaving many people to live out their final days in unnecessary extreme emotional pain. As early as 1910, Emil Kraepelin, father of modern psychopharmacology, referenced depression among the elderly as involutional melancholy. Since then, the breakdown of traditional caretaking structures and the removal from old people of any sense of importance have made things worse. Older people in nursing homes are more than twice as likely to be depressed as those who live in the world—in fact, it has been suggested that more than a third of those resident in facilities are significantly depressed. It is striking that the effects of placebo treatment on elderly patients are substantially higher than the norm. This would suggest that these people are experiencing some benefit from the circumstances around the taking of a placebo, beyond the conventional psychosomatic benefits of believing that one is receiving medication. The monitoring and close interviews that are a part of charting a study, the careful regulation and the focus for the mind, are having a meaningful effect. Old people feel better when more attention is paid to them. The elderly in our society must be horrifyingly lonely for this small response to give them such a lift.

While the social factors that lead to depression among the elderly are powerful, it would appear that important organic shifts also affect mood. Levels of all neurotransmitters are lower among old people. The level of serotonin in people in their eighties is half of what it would have been in the same people in their sixties. Of course the body is at this stage of life going through many metabolic shifts and much chemical rebalancing, and so diminishing neurotransmitter levels do not have the same immediate effect (so far as we know) as they would in a younger person whose serotonin levels were suddenly reduced by half. The extent to which brains change in plasticity and function with age is also reflected in the fact that antidepressant treatment takes a particularly long time to kick in for old
people. The same SSRIs that in a midlife adult will begin to work within three weeks will in an elderly patient often take twelve weeks or longer to be effective. The rate of successful treatment, however, is not altered by age; the same proportion of people is treatment-responsive.

Electroconvulsive therapy is frequently indicated for the elderly for three reasons. The first is that, unlike medications, it acts rapidly; letting someone get more and more depressed for months before his meds begin to alleviate his despair is not constructive. Additionally, ECT does not have adverse interactions with other medications that elderly people may be taking—such interactions can in many cases limit the range of antidepressants that can be prescribed. Finally, depressed elderly people often have lapses in memory and may forget to take their medication or may forget that they have taken it and take too much. ECT is much easier to control in this regard. Short-term hospitalization is often the best way to care for older people who are experiencing severe depression.

Depression can be hard to spot in these populations. The libido issues that are important elements of depression among younger people do not play so significant a role among the elderly. They feel guilty less often than do younger depressives. Instead of getting sleepy, older depressed people tend to be insomniac, lying awake at night in the grip, often, of paranoia. They have wildly exaggerated catastrophic reactions to small events. They tend to somaticize a lot, and to complain of an enormous number of peculiar aches and pains and atmospheric discomforts: This chair isn’t comfortable anymore. The pressure in my shower is down. My right arm hurts when I pick up a teacup. The lights in my room are too bright. The lights in my room are too dim. And so on, ad infinitum. They develop irritable characteristics and become grumpy, often showing a distressing emotional bluntness with or an emotional indifference to those around them and occasionally manifesting “emotional incontinence.” These symptoms respond most frequently to the SSRIs. Their depression is often either a direct consequence of shifting organic systems (including lower blood supply to the brain) or a result of the pain and indignity of bodily decay. Elderly dementia and senility are often accompanied by depression, but the conditions, though they may occur together, are different. In dementia, the capacity for automatic mind functions goes down: basic memory, especially short-term, is compromised. In depressed patients, psychologically effortful processes are blocked: long-term complex memories become inaccessible, and processing of new information is impeded. But most elderly people are unaware of these distinctions, and they suppose the depression symptoms to be the quality of age and mild dementia, which is why they so often fail to take basic steps to ameliorate their situation.

One of my great-aunts fell in her apartment and broke her leg when she was in her late nineties. The leg was set, and she came home from the hospital with a team of nurses. She clearly found it hard to walk at first, and only with difficulty could she do the exercises set for her by her physiotherapist. A month later, her leg had healed remarkably well, but she was still afraid of walking and continued to struggle against locomotion. She had become accustomed to a commode, which could be brought to her bedside, and she refused to go the fifteen feet to get to the toilet. Her lifelong vanity was suddenly gone, and she refused to go to the hairdresser, whom she had visited twice every week for nearly a century. In fact, she refused to go out at all and kept postponing a visit to a podiatrist despite an ingrown nail that must have been painful. Weeks went by like this in her claustrophobic apartment. Meanwhile, her sleep was irregular and disturbed. She refused to talk to my cousins when they called her. She had always been meticulous about her personal affairs and somewhat secretive about details; now she asked me to open and pay her bills as they were too confusing for her. She couldn’t assemble simple information—she’d ask me to repeat eight times my plans for the weekend, and this cognitive retardation seemed almost like senility. She grew repetitive, and though she was not sad, she was altogether diminished. Her GP insisted that she was just experiencing some trauma-related stress, but I saw that she was getting ready to die and believed that this was an inappropriate response to a broken leg, no matter how old she was.

I finally persuaded my psychopharmacologist to come to her apartment and talk to her, and he immediately diagnosed severe old-age depression and put her on Celexa. Three weeks later, we had an appointment with her podiatrist. I pressed her to come out in part because I thought her foot wanted attention, but mostly because I thought it was necessary for her to venture into the world again. She looked at me with anguish when I made her come outside and seemed to find the entire thing utterly debilitating. She was confused and frankly terrified. Two weeks later, we had an appointment with the doctor who had set her leg. I arrived at her apartment to find her in an attractive dress with her hair combed and some lipstick on, wearing a little pearl brooch that she had often sported in happier days. She came downstairs without complaining. She clearly found our outing stressful, and she was fractious in the doctor’s office, and a bit paranoid, but when the surgeon came in, she was charming and quite articulate with him. At the end of her visit, her nurse and I wheeled her back toward the door of the building. She was pleased to learn that her leg had healed nicely and thanked everyone profusely. I was exultant at every sign of reawakening in her, but nothing had really prepared me for her to say, as we were leaving, “Darling, shall
we go out to lunch?” And we went to a restaurant we used to like, and with my help she even walked a short distance in the restaurant, and we told little stories and laughed, and she complained that her coffee was not hot enough and sent it back, and she was
alive
again. I cannot say that she then returned to regular lunching, but thereafter she consented to go out once every few weeks, and her basic coherence and sense of humor gradually returned to her.

Six months later, she developed what turned out to be internal bleeding of minor significance, and had a three-day hospitalization. I was concerned about her, but was pleased that her mood was resilient enough so that she could cope with the hospital entry without becoming panicked or confused. A week after she came home, I visited her and checked to make sure she had sufficient supply of all her medications. I noticed that the Celexa bottle was about as full as it had been when I checked it previously. “Have you been taking these?” I asked her. “Oh, no,” she said. “The doctor told me to stop taking them.” I assumed that she must have misunderstood, but her nurse had been present when these instructions had been given and confirmed them. I was frankly astonished and horrified. Celexa has no gastroenterological side effects, and that it had been implicated in her bleeding seemed highly unlikely. There was no good reason for terminating it, and there could be no good reason for terminating it so abruptly; even someone young and fit should go off antidepressant medication gradually and according to a clear program. Someone who is receiving substantial benefit from medication should not be taken off it at all, but the gerontologist who treated my aunt had whimsically decided that it would be good for her to go off any “unnecessary” medications. I called that doctor and screamed holy hell down the line, wrote an outraged letter to the president of the hospital, and told my aunt to return to her medication. She is living rather happily and less than a month from her hundredth birthday as this book goes to press. We are going to the hairdresser in two weeks so that she’ll look her best for the little party we’re planning to throw. I go to visit her every Thursday, and our afternoons together, which were once a leaden burden, are now full of fun; when I gave her some good family news a few weeks ago, she clapped her hands and then started to sing. We talk about all kinds of things, and I have recently benefited from her wisdom, which came creeping back to her along with the gift of joy.

Depression is often a precursor state to severe impairment of the mind. It appears to predict, to some degree, senility and Alzheimer’s disease; those diseases in turn may coexist with or kindle depression. Alzheimer’s appears to lower serotonin rates even further than does aging. We have severely limited capacities to alter the confusion and cognitive
decay that are the essence of senility or Alzheimer’s, but we can alleviate the acute psychic pain that often accompanies those complaints. Many people are disoriented without being frightened or deeply sad, and this is, for the moment, a state we can achieve with these populations—but usually don’t. Some experimentation has been done to gauge whether lowered levels of serotonin may be responsible for senility, but it seems more likely that dementia follows up on damage to various brain areas, including those responsible for serotonin synthesis. In other words, the senility and the lowered serotonin are separate consequences of a single cause. It appears that SSRIs do not have much influence on motor skills or intellectual skills that are damaged by senility; but better mood frequently allows older people to make better use of the capacities that are still organically present in them, and so there may be in practical terms a certain degree of cognitive improvement. Alzheimer’s patients and other depressed elders also seem to respond to atypical medications such as trazodone, which are not usual first-line treatments for depression. They may also respond to benzodiazepines, but these tend to make them overly sedated. They respond well to ECT. The fact that they are incoherent need not consign them to misery. Among the patients who show sexual aggressivity in Alzheimer’s—a not uncommon situation—hormone therapies may help; but this seems to me to be rather inhumane unless the sexual feelings are causing misery to those who experience them. Patients with dementia are not usually responsive to talking therapies.

Depression is also often a result of stroke. People in the first year after stroke are twice as likely to develop depression as are others. This may be the result of physiological damage to particular parts of the brain, and some research has suggested that strokes in the left frontal lobe are particularly likely to disregulate emotion. After initial recovery, many older people who have had strokes are given to terribly intense bouts of crying at slight matters negative or positive. One patient after a stroke burst into tears between twenty-five and a hundred times a day, each bout lasting between one and ten minutes, and this left him so exhausted he could hardly function. Treatment with an SSRI rapidly brought these crying fits under control; as soon as the patient went off the drug, however, the crying returned, and he is now permanently on medication. Another man who had had to give up work entirely for ten years because of depression that followed a stroke was given to fits of tears; treatment with an SSRI got him up and running again, and in his late sixties he returned to work. There is no question that strokes in certain areas of the brain have emotionally devastating consequences, but it appears that, in many instances, those consequences can be controlled.